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SOCCER ACCIDENT INSURANCE For members registered with the AYSO National Support Center Contact: Andrea McIntosh Email: [email protected] Phone: 800-342-4371 Fax: 770-512-5050 SAI Policy Limits The Soccer Accident Insurance (“SAI”) underwritten by American National Life Insurance Company of Texas, pays medical costs up to $50,000 maximum per claim to an insured person for accidental bodily injuries incurred as a direct result of participation in a covered activity. This is a Full Excess Policy, and all claims will be paid on a Usual & Customary basis. Each claim is subject to a $200 Deductible Other benefits under the policy are • • • • $5,000 for Accidental Death & Dismemberment $3,500 for dental expenses resulting from accidental injury or loss to sound, natural teeth $50,000 Maximum Medical Expenses $1,000 Physical Therapy and Chiropractic Limit Ver: SAI Brochure English ESIX v081903-1.doc Enhanced coverage include • Expanded Medical Benefit: The policy will include coverage for Eligible Expenses resulting from conditions (such as blisters, tennis elbow, heat exhaustion, hernia, shin splints, bursitis, stress fractures, chronic soreness or pain, tendonitis, strains, sprains, etc.) which are a normal, foreseeable result of a sports or policyholder function covered under the terms of the policy. • Heart or Circulatory System Malfunction Benefit: The policy will include coverage for Eligible Expenses incurred by a Covered Person as a result of heart or circulatory system malfunction which: Is first diagnosed and treated while participating in a Policyholder’s covered Sponsored Activity (or within 24 hours after participation); and The Covered Person has not previously received medical advice, diagnosis and care or treatment, including the use of prescription drugs for such heart or circulatory system malfunction. If the Covered Person suffers loss of life resulting from heart or circulatory system malfunction within 90 days from the date of participation in the Policyholder’s covered Sponsored Activity, a benefit amount is payable as shown under the Principal Sum of the Accidental Death & Dismemberment Benefit. • Pre-existing Injury Benefit: The policy will include coverage for Eligible Expenses resulting from re-injury or aggravation of an injury that occurred prior to the effective date of this policy. In order to be eligible for this coverage, the Covered Person must: Have received a written medical clearance from a Doctor to participate in the covered Policyholder’s function or sport; and be participating in a covered Policyholder’s function or sport when the re-injury or re-aggravation occurs. Who is Covered? All AYSO registered players, coaches, referees, and volunteers are covered for accidental bodily injury while participating in the following activities: • Scheduled games, tournaments, team practice sessions or other sponsored activities, provided they are under the direct supervision of a team official. • Group travel directly to or from such games, tournaments, practice sessions or sponsored activities, provided that players are traveling as a team and a licensed adult driver operates the vehicle. What is Covered? • Medical/surgical treatment by a doctor or dentist Ver: SAI Brochure English ESIX v081903-1.doc • • Services of a licensed or graduate nurse Stays in a hospital How to File an SAI Claim The claimant must do the following • Obtain an AYSO “Soccer Accident Insurance” (“SAI”) Claim form from your regional safety director or commissioner. • Complete the portions of the claim form marked “To be completed by claimant,” and “Statement of insurance.” • “Eligibility verification”: Secure signatures from the two authorized AYSO officials: the safety director and the regional commissioner. • Be sure the authorized AYSO officials have fully completed every section of PART A including the AYSO region number and a valid AYSO ID number before you mail the claim form. Claim forms without this information can not be processed. • It is the responsibility of the claimant to make a copy for his own records and then mail the claim form to Dianna Taormina, American National Life Insurance Co. of Texas. within 90 days of the date of injury. If you or your parents are covered by any other health care plan, you must submit your bills to the other plan first. After your other plan has paid their share of the claim, you may then submit any remaining balances to the AYSO plan. Be sure to send copies of all itemized bills and the Explanation of Benefits Form outlining the benefits paid under your primary plan. • Send your claim form with all relevant documents to: Dianna Taormina American National Life Insurance Co. of Texas AYSO Accident Claims The Loomis Company P.O. Box 13906 Reading, PA 19612 e-mail: [email protected] (610) 374-4040 ext. 2253 (888) 585-7065 Ver: SAI Brochure English ESIX v081903-1.doc • Full Excess means you must submit your medical bills to any other applicable health care plan you have in force, prior to making a claim under this policy. If your medical coverage is under an HMO or similar plan, you must follow their rules for obtaining benefits; otherwise no benefits will be paid under this policy. • If there is no other insurance available to the participant, the claim will be processed on a primary basis. • Usual & Customary means claims will be paid for medical fees and services that do not exceed those generally charged for similar Medical Care in your area. • The Benefit Period under this policy is 104 weeks. This means coverage is provided only for medical or dental expenses incurred within 104 weeks of the date of injury. What is not Covered? • Costs of medical services or treatment given by any persons employed or retained by the insured • Any bacterial infection not caused by an accidental cut, wound or food poisoning • Declared or undeclared acts of war • Any loss caused by or resulting from illness or disease • Eyeglasses, contact lenses or Hearing aids • Intentionally self-inflicted wounds, suicide (while sane or insane) or attempted suicide. Note This brochure provides a summary of coverage only. For a full description of the policy terms, conditions and exclusions please refer to the actual policy. Ver: SAI Brochure English ESIX v081903-1.doc